INTRODUCTION: Multiple myeloma (MM) classically presents with hypercalcemia and renal failure. Clinical course may be complicated by respiratory failure, but it is rarely observed prior to diagnosis. We present a case where an uncommon MM variant presented as acute multi-organ failure.

DISCUSSION: Hyperlipidemic myeloma (HLM), more commonly seen with the IgA subtype, accounts for 6% of MM cases. Typically diagnosis is delayed, with xanthomas or hyperlipidemia preceding other symptoms by years. Patients have been described as having “orange skin,” or carotenoderma. The underlying mechanism of the hyperlipidemia remains unclear. Respiratory failure is uncommon at presentation, but one-third of MM patients later develop pulmonary infectious complications, due to immunocompromised status. This patient’s underlying MM likely predisposed him to multi-organ failure and respiratory failure triggered by influenza, with lab abnormalities prompting workup for malignancy.

CONCLUSIONS: MM uncommonly presents with acute multi-organ failure, including respiratory failure. Hyperlipidemia, xanthomas, or carotenoderma may portend development of the rarer variant, HLM. Hematologic malignancies should be considered in the differential for patients with multi-system dysfunction, not otherwise explained.

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